Cycle 1
Health 2024-08-29 · Fire 2024-08-29
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Honolulu, HI
Oahu Care Facility
2-star overall rating with 2-star inspections with $8,278 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1808 South Beretania Street, Honolulu, HI
(808) 973-1900
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-09-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.66
Registered nurse staffing · state 1.63 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.36 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.73 · national 2.35
Total nurse hours
4.68
All reported nurse hours · state 4.71 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.97 · national 1.54
Weekend hours
4.18
Weekend nurse staffing · state 4.19 · national 3.43
Weekend RN hours
1.31
Weekend registered nurse coverage · state 1.23 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.68
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 33% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 37% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,562
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0107
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.01
Performance 17.26% · Measure score 9.01 · Achievement 9.01 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.58
Performance 7.06% · Measure score 2.58 · Achievement 2.58 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.05
Baseline 87.10% · Performance 46.34% · Measure score 6.05 · Achievement 4.24 · Improvement 6.05
Adjusted total nurse staffing
4.63
Baseline 4.70 hours · Performance 4.39 hours · Measure score 4.63 · Achievement 4.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 10% · Lower 95% interval 7.14% |
| Discharge to community | 68.11% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 89 · Observed rate 59.55% · Lower 95% interval 57.88% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.17% |
95.27%
1.9 pts better
|
Numerator 103 · Denominator 106 |
| Falls with major injury | 1.89% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 106 |
| Discharge self-care score | 57.97% |
53.69%
4.3 pts better
|
Numerator 40 · Denominator 69 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 30 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 5.66% |
2.29%
3.4 pts worse
|
Numerator 6 · Denominator 106 · Adjusted rate 5.83% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 7.41% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 29.67% |
8.2%
21.5 pts better
|
Numerator 27 · Denominator 91 |
| Staff flu vaccination coverage | 29.13% |
42%
12.9 pts worse
|
Numerator 37 · Denominator 127 |
| Discharge function score | 46.38% |
56.45%
10.1 pts worse
|
Numerator 32 · Denominator 69 |
| Transfer of health information to provider | 93.55% |
95.95%
2.4 pts worse
|
Numerator 29 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 6 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
96.3%
5.1 pts worse
|
93.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 93.8% · Q3 87.5% · Q4 91.4% · 4Q avg 91.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
1.9%
1.3 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
1.4%
1.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
4.9%
2.1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 3.0% · Q4 3.1% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
8.2%
2.4 pts worse
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 10.3% · Q3 9.1% · Q4 18.8% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
11.3%
5.1 pts worse
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 15.2% · Q3 16.1% · Q4 17.2% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
23.4%
1.6 pts better
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
16.8%
6.4 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 11.8% · Q3 10.0% · Q4 14.3% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.3%
1.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
2.4%
1.2 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.1% · Q3 2.5% · Q4 5.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
17.8%
8.2 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.0% · Q2 32.0% · Q3 18.4% · Q4 32.5% · 4Q avg 26.0% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
3.6%
0.5 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.9% · Q3 1.8% · Q4 2.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 57.6% |
82.8%
25.2 pts worse
|
81.7%
24.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 52.1% · Q2 43.7% · Q3 57.8% · Q4 72.9% · 4Q avg 57.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
10.9%
4.2 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 7.3% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.0%
2.2 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.6% · Q3 3.9% · Q4 4.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.0% |
84.7%
28.7 pts worse
|
79.7%
23.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
19.6%
3.3 pts worse
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 26.0% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-17 · Fire 2023-10-17
12 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-11-03 · Fire 2022-11-03
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-29
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-09-18
D · Potential for more than minimal harm
2023-10-17
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-11-16
D · Potential for more than minimal harm
2023-10-17
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-11-16
D · Potential for more than minimal harm
2022-11-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-29
Inspection history
Recent health citations
G · Actual harm
2025-03-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-03-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-03-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-16
D · Potential for more than minimal harm
2025-03-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-16
F · Potential for more than minimal harm
2024-08-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-29
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-30
E · Potential for more than minimal harm
2023-10-17
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-10-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-17
E · Potential for more than minimal harm
2023-04-05
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-04-05
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-04-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-04-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-26
F · Potential for more than minimal harm
2022-11-03
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-12-02
F · Potential for more than minimal harm
2022-11-03
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-03
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-03
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-02
Penalties and ownership
What sits behind the stars
$8,278
2025-03-25
Fine
Fine · fine $8,278
Fine
Ownership
Pacific Skilled Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Olsen, Spencer
5% Or Greater Indirect Ownership Interest · Individual
Mayer, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Sorensen, Kristen
5% Or Greater Indirect Ownership Interest · Individual
Kim, Olivia
Operational/Managerial Control · Individual
Kim, Olivia
Corporate Officer · Individual
Kim, Olivia
W-2 Managing Employee · Individual
Lefler, Tyrus
Corporate Officer · Individual
Olsen, Spencer
Corporate Officer · Individual
Pang, Brian
Corporate Officer · Individual
Yoshida, Cynthia
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Islands Skilled Nursing & Rehabilitation
Honolulu, HI
2-star overall rating with 2-star inspections with Special Focus status with $89,206 in total fines with 14 recent health deficiencies
#2
Hale Ola Kino By Arcadia
Hon, HI
5-star overall rating with 4-star inspections with 6 recent health deficiencies
#3
Arcadia Retirement Residence
Honolulu, HI
5-star overall rating with 3-star inspections with $12,854 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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